Otitis Media, Chronic

Essentials of Diagnosis

• Chronic otorrhea with or without otalgia

• Tympanic membrane perforation with conductive hearing loss

• Often amenable to surgical correction

General Considerations

• Generally develops as a consequence of recurrent acute otitis media, although it may follow other diseases and trauma

• The bacteriology of chronic otitis media differs from that of acute otitis media; common organisms include

  • Pseudomonas aeruginosa

  • Proteus species

  • Staphylococcus aureus

  • Mixed anaerobic infections

• Purulent aural discharge

• Drainage may be continuous or intermittent, with increased severity during upper respiratory tract infection or following water exposure

• Pain is uncommon except during acute exacerbations

• Conductive hearing loss results from destruction of the tympanic membrane or ossicular chain, or both

• Perforation of the tympanic membrane is usually present; may be accompanied by

  • Mucosal changes, such as polypoid degeneration

  • Granulation tissue and osseous changes, such as osteitis and sclerosis

Medication

• Regular removal of infected debris

• Use of earplugs to protect against water exposure

• Topical antibiotic drops (eg, ofoxacin 0.3% or ciprofloxacin with dexamethasone) for exacerbations

• Ciprofloxacin, 500 mg orally twice a day for 1–6 weeks, may help dry a chronically discharging ear

Surgery

• Tympanic membrane repair may be accomplished with temporalis muscle fascia

• Successful reconstruction of the tympanic membrane may be achieved in about 90% of cases, often with elimination of infection and significant improvement in hearing

• When the mastoid air cells are involved by irreversible infection, they should be exenterated at the same time through a mastoidectomy

Complications

• Cholesteatoma

  • A special variety of chronic otitis media

  • Most common cause is prolonged eustachian tube dysfunction, with inward migration of the upper flaccid portion of the tympanic membrane

  • Typically erode bone, with early penetration of the mastoid and destruction of the ossicular chain

  • Over time they may erode into the inner ear, involve the facial nerve, and on rare occasions spread intracranially

  • Otoscopic examination may reveal an epitympanic retraction pocket or a marginal tympanic membrane perforation that exudes keratin debris, or granulation tissue

  • Treatment involves surgical marsupialization of the sac or its complete removal

• Petrous apicitis

  • The medial portion of the petrous bone between the inner ear and clivus may become a site of persistent infection when the drainage of its pneumatic cell tracts becomes blocked

  • Foul discharge, deep ear and retro-orbital pain, and sixth nerve palsy (Gradenigo syndrome) may result

  • Meningitis may be a complication

  • Treatment is with prolonged antibiotic therapy (based on culture results) and surgical drainage via petrous apicectomy

• Facial paralysis

  • Usually evolves slowly due to chronic pressure on the seventh nerve in the middle ear or mastoid by cholesteatoma

  • Treatment requires surgical correction of the underlying disease

  • Prognosis is less favorable than for facial palsy associated with acute otitis media

  • See also Otitis Media, Acute

• Sigmoid sinus thrombosis

  • Trapped infection within the mastoid air cells adjacent to the sigmoid sinus may cause septic thrombophlebitis

  • This is heralded by signs of systemic sepsis (spiking fevers, chills), at times accompanied by signs of increased intracranial pressure (headache, lethargy, nausea and vomiting, papilledema)

  • Diagnosis can be made noninvasively by magnetic resonance venography

  • Primary treatment is with intravenous antibiotics (based on culture results)

  • Surgical drainage with ligation of the internal jugular vein may be indicated when embolization is suspected

• Central nervous system infection

  • Results either from passage of infections along preformed pathways such as the petrosquamous suture line or from direct extension of disease through the dural plates of the petrous pyramid

  • Epidural abscesses

    • Arise from direct extension of disease in the setting of chronic infection

    • They are usually asymptomatic but may present with deep local pain, headache, and low-grade fever

    • They are often discovered as an incidental finding at surgery

  • Brain abscess

    • May arise in the temporal lobe or cerebellum as a result of septic thrombophlebitis adjacent to an epidural abscess

    • The predominant causative organisms are S aureus, Streptococcus pyogenes, and Streptococcus pneumoniae

    • Rupture into the subarachnoid space results in meningitis and often death

  • See also Otitis Media, Acute